Provider Demographics
NPI:1376175166
Name:CROLL, KATHLEEN M
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:CROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 HOOPER AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8175
Mailing Address - Country:US
Mailing Address - Phone:848-223-7120
Mailing Address - Fax:732-349-6919
Practice Address - Street 1:1868 HOOPER AVE STE 6
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8175
Practice Address - Country:US
Practice Address - Phone:848-223-7120
Practice Address - Fax:732-349-6919
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH059922-23363LF0000X
NJ26NJ01043211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily